3 Top Challenges Facing Skilled Nursing Executives


3 Top Challenges Facing Skilled Nursing Executives Right Now…and How to Solve Them

It’s an understatement to say that the past year has been a difficult one for the skilled nursing industry. COVID-19 hit SNFs very hard, in terms of both health impacts and public perception. At the beginning of this year, census rates in every state averaged below 80%.

Not only did the pandemic introduce new challenges, but it acted as an accelerant for many of the issues SNFs were already facing — declining occupancy, high staff turnover, shrinking profitability, and so on. It was a perfect storm, but it has also provided an opportunity (perhaps an imperative) for skilled nursing executives to reexamine their operations and make improvements that will sustain their business into the future.

This article reviews three of those top challenges and provides tips on how skilled nursing leadership can set their organizations up for success.

Challenge 1: Regulatory enforcement

SNFs came under the regulatory microscope very early in the pandemic. On March 3, 2020, then Attorney General William Barr announced the launch of a National Nursing Home Initiative to “coordinate and enhance civil and criminal efforts to pursue nursing homes that provide grossly substandard care to their residents.” At that time, 30 SNFs in nine states were already the subject of active investigations.

The next day, the Centers for Medicare & Medicaid Services (CMS) announced that it would immediately focus its facility inspection efforts on infection control and other serious health and safety threats. Six months later, in August 2020, CMS announced that the number of immediate jeopardy (IJ) level findings for infection control had tripled compared to the year before, with the agency imposing more than $15 million in penalties for noncompliance.

According to legal experts, SNFs can expect these types of actions to continue. Attorney Tom Selby told Skilled Nursing News that he anticipates the number of IJ-level findings for infection control to quadruple or quintuple.

Jon Ferry, a former federal prosecutor who handled many healthcare investigations, agrees that government enforcement agencies will continue to investigate SNF responses to the pandemic. Writing for McKnights, he warns against “the coming enforcement storm.”

Solution: Be prepared and gather documentation

Both Selby and Ferry advise that the key to weathering the storm is being prepared, especially with documentation of all infection control protocols.

Here are their recommendations:

  • Conduct a self-evaluation of infection control procedures to identify problems before the inspectors arrive.
  • Take corrective actions for any known issues — Ferry notes that preemptive corrective actions go “a long way in convincing prosecutors and investigators that a company is operating in good faith.”
  • Document all efforts to keep residents safe. Be sure to gather documentation from early in the pandemic.
  • Ensure all staff has necessary personal protective equipment (PPE) — See the Occupational Safety and Health Administration’s (OSHA) directive on the new COVID-19 National Emphasis Program for more information about keeping employees safe.
  • Consider hiring an infection control and quality assurance nurse — This tip comes from Rev. Dr. Derrick DeWitt, who successfully kept COVID-19 out of his 30-resident nursing home. Read an interview with DeWitt in Skilled Nursing News.

Challenge 2: Low census

As mentioned earlier, skilled nursing occupancy rates across the country averaged below 80%. In some states, it was much lower — Texas reported average occupancy of only 56%.

Much of this decline appears to be related to increases in hospital discharges to home health. An analysis by Avalere health revealed that early in the pandemic, discharges to both SNFs and home health agencies declined significantly. However, the recovery has been uneven, with the percentage of discharges to home health returning to pre-pandemic levels by the summer of 2020, while the percentage of discharges to SNF remained depressed.

Avalere notes that “in the longer term, changes in care delivery broadly as a consequence of COVID-19 may influence how post-acute care is utilized following hospital discharge.” In other words, SNFs may struggle to reach pre-pandemic discharge levels anytime soon.

Solution: Reduce hospital readmissions

Hospitals look at readmission rates to decide where to refer post-acute patients. Not only that, but under the new Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program, Medicare now adjusts its payments based on the quality of care as measured by hospital readmissions.

The research shows that there’s plenty of room for improvement. A 2019 study of 67,000 heart failure patients who were discharged to a SNF and then to home found that nearly one-quarter of them were readmitted within 30 days of SNF discharge. The authors suggest improving the discharge process is key to reducing readmissions.

By taking action to reduce your readmission rates, you can make your facility more attractive to referrers and also ensure you receive Medicare incentive payments rather than penalties.


  • Track your readmission rates so you have the data at hand when hospitals inquire.
  • Implement systematic follow-up after each discharge to increase patient engagement.

Solution: Improve liaison outreach activities and performance

SNFs will need to redouble their efforts to improve liaison outreach activities and performance. This includes ensuring hospital referrals are processed quickly and accurately so they can be followed up on in a timely manner. Read more about the importance of fast follow-up.


  • Use technology, such as a CRM, to better understand where referrals are coming from so liaisons can focus their outreach on the most valuable referral sources.
  • Follow up on all leads, including web leads, promptly. Data from our recent benchmark report revealed that, while other lead sources declined in 2020, the number of web leads increased. Marketing automation software ensures you follow up each and every one of these leads in a timely manner. Read more about marketing automation.
  • Capture liaison knowledge in a knowledge base so you can continue to manage key relationships when employees turn over.

Challenge 3: Lack of reliable data

Several of the recommendations above rely on having good data. If you don’t have data about your referral sources, you can’t determine which are the most valuable. If you don’t have data about your hospital readmission rates, you can’t use this information to appeal to institutional referrers or make plans to improve your operations if necessary.

One of the biggest data gaps in the skilled nursing industry is between SNFs and their hospital partners. A survey of nearly 500 hospital-SNF pairs published earlier this year found a general lack of accurate and timely data sharing.

The survey assessed information based on three characteristics: completeness, timeliness, and usability. Only 13.5% reported excellence on all three measures, while almost one-third (30%) were below average on every measure. The researchers conclude that the lack of information sharing is “likely associated” with poor patient transitions.

Solution: Interoperability

Between EHR/EMR, CRM, POC, and the many other technologies used in healthcare settings, it’s easy for data to get siloed. That’s why interoperability should be one of the key capabilities of any software you choose for your facility.

An interoperable system brings everything together via integrations, so that you (and your partners) can have access to the data you need to not only provide optimal transition experiences, but deliver better results across the board — to patients and residents, as well as to your financial stakeholders. Download our white paper, “3 Ways to Drive Skilled Nursing Facility Margins with Data,” for more about how better data can boost your bottom line.

Enquire is a leading provider of cloud CRM, marketing automation, and contact center solutions for senior living communities, post-acute care facilities, and healthcare organizations. Learn more about our census solutions for skilled nursing facilities.

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